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Reform / Living to be 500, death by asteroid, and the inevitability of NHS reform Reform / Living to be 500, death by asteroid, and the inevitability of NHS reform while typically the private sector succeeds by showing how well it is doing, the public sector often declaims its own failure in the hope of extracting more government spending.
And, partly, it’s because publicly-funded healthcare means collective decisions about who will get what – the very essence of politics, and ethics. So, like the proxy wars fought by Cold War superpowers in far-off places, what are putatively local conflicts – in this case “health policy debates” – often turn out to be manifestations of far deeper ideological clashes. About state versus market. Freedom versus solidarity. Autonomy versus paternalism. No wonder these zombie “NHS” controversies keep reappearing, continually inverting discussion of “ends” with debates about “means”.
Such then is the terrain on which all NHS reform plays out. But the new If you’re prone to pessimism, there’s much to depress you as you survey the coming government is also confronted by two further paradoxes. decade and beyond. A throbbing economic hangover from the worst global NHS reform is most urgent when funding is tight. But, historically, NHS recession in a century. The seven billionth human contribution to climate change. reform has needed substantial budgetary lubrication (the Clarke reforms of the And for those with an apocalyptic streak, Astronomer-Royal Martin Rees’s early 1990s and the Blair reforms of the 2000s being just the most recent examples). prediction of a one-in-two chance that our species will be extinct by 2100.
In constrained circumstances, policymakers often, therefore, resort to short term But for those of a more cheerful disposition, consider Steven Pinker’s expedients. Of the needed NHS efficiency gains over the next several years, the recent observation that violence has declined such that we are now living in the Department of Health says that at least four fifths will come from a top-down staff most peaceful epoch in human history. Or reflect on the perhaps somewhat pay freeze and a hospital pricing squeeze. So the first paradox is that, despite the tongue-in-cheek claim I heard from one of the world’s leading Nobel-winning Sturm und Drang over the new Government’s decentralising health legislation, in geneticists at Davos last year that breakthroughs in cell biology could mean practice the NHS is once again in a highly centralising moment. In time, the attempt human life expectancies of 500 years. And that within two decades we may be to run the NHS as if it were one big hospital will inevitably again be superseded. able to pinpoint advanced life forms elsewhere in the universe. Managing that transition – against the backdrop of continuing austerity – is going Set against such profound possibilities – that surely rival the invention of to require exceptional sophistication in policy design, political stewardship, agriculture, the Copernican revolution or Gutenberg’s printing press – rehashed managerial execution, clinical engagement, and public communication, if a crash debates about British public sector reform seem thin gruel. But controversial these reforms always are, and nowhere more so than in the NHS.
In designing that transition, policymakers are faced with a second paradox. Why is that? And how should we reconcile the facts of steadily improving Improving population health, care quality and service efficiency mostly requires patient care and population health with the periodically-recurring narrative of an changes in how clinical care is delivered and how patients are engaged. Yet most NHS reforms focus instead on rearranging the administrative deck chairs, Partly, it’s because of the NHS’s tax-funding mechanism, which means particularly the layer of management that sits between Whitehall and the GP that whenever the post-war British economy sneezes, the NHS catches a cold. In surgery or the hospital. In part, this is a genuine – if ultimately unsuccessful – 1951, 1968, 1976, 1987-88 and 1999, the infection nearly proved fatal. So, despite attempt to try and upgrade the effectiveness of these “intermediate tier” its effectiveness as a reasonably equitable, if somewhat crude cost control organisations.61 But, in part, this is also displacement activity. It avoids asking – mechanism, the inevitable lumpiness of NHS tax-funding has also meant long and having to answer – the far tougher questions about what the NHS and its staff periods of relative underfunding, followed by acute but avoidable crises, and then bursts of compensatory but inflationary “catch-up” spending. And, since Britain For example, how is it that only half of NHS diabetes patients get the has not in fact eliminated economic boom and bust (just as “history” did not in fact “end” with the collapse of the Berlin Wall), the NHS now faces its deepest and 61 These periodical y reincarnated entities exhibit a limited set of naming permutations down the most sustained budget crunch since 1948.
years: health authorities, area health authorities, district health authorities, strategic health Partly, too, it’s because – as Canadian academic Bob Evans has noted – authorities, regional health authorities, regional offices, primary care groups, clinical commissioning groups, primary care trusts, and so on.
Reform / Living to be 500, death by asteroid, and the inevitability of NHS reform Reform / Living to be 500, death by asteroid, and the inevitability of NHS reform evidence-based care they need – with a five-fold variation across the country?62 How can there be a 40 per cent difference in local rates of age-standardised NHS What is the regulatory and policy regime best placed to help the NHS do so? hip replacements, cataract surgeries and gall bladder operations?63 How can a Some of the active ingredients are: actively empower patients so their needs and quarter of NHS trusts get away with having their “value for money” accounts preferences continually reshape care delivery; align incentives, information and qualified by their auditors?64 How can a fifth of hospitals treat their older patients decision rights with the frontline health professionals who can best effect without dignity or compassion?65 Why is it that nearly a third of health care improvement; remove barriers that block job redesign and new ways of working; organisations say they still lack a system for monitoring the performance of look sceptically at organisational monopolies created in the name of integration; medical practitioners?66 And how is it that a single hospital in mid-Staffordshire prefer rapid experimentation, adaptive feedback loops, and emergent organisational could have been responsible for killing its patients at a level equivalent to two or configurations over one-size-fits all solutions from Whitehall; stimulate pluralism more Lockerbie air crashes, yet apparently no one noticed or did anything?67 by ensuring level playing fields for new entrants; strengthen scrutiny of clinical These are the inconvenient truths that any fundamental reform care, and introduce full public transparency on performance variation; and ensure programme would tackle. Genuine reform would also help “future proof” the the overarching structure of health system regulation is fit-for-purpose.
health service against major environmental trends headed its way, such as the If “to will the end is to will the means”, these are some of the agenda items ageing population, the rise of chronic diseases, and a decline in paternalism. It that NHS reformers will have to pursue over the coming few years. But, as the would do so in part by taking full advantage of some important opportunities.
King James Bible puts it: “where there is no vision, the people perish”.70 So, rather On the demand side, at a time when six out of ten British adults are than framing the debate on the future of the NHS in narrowly technocratic terms, overweight or obese, the new science of consumer behavioural change has clear or as an unpalatable but unavoidable response to austerity, reformers should also implications for prevention and health, which the wider debate on food policy, paint an optimistic and inspiring vision of what progress could mean for patients urban design and the like should not obscure.68 As important will be the future of and for health professionals as the 21st century unfolds.
informal voluntary care. Valued at £119 billion a year, and functioning as a hidden “heat sink” (the Big Society in action?), its rise or fall will have profound implications for the sustainability of formal tax-funded health and social services. On the supply side, as biology becomes an information science, as the cost of personal gene sequencing falls from up to $3 billion to perhaps $1000, and as digitisation opens the way for profound changes in how medicine and healthcare is delivered, will the NHS embrace or resist the new possibilities presented by personalised medicine, nano-robots, vaccinations against virus-inducing cancers, tissue engineering, and neuro-assisted devices – to name but a few of the technologies that are headed our way? Doing so holds out the prospects of important advances in health and well-being, but will mean weaning the NHS off anachronistic 62 Department of Health (2010), NHS Atlas of Variation. 69 Imagine for example a new medicine that could reduce the risk of diabetes by 58 per cent: 63 Appleby, J. et al. (2011), Variations in health care – the good, the bad and the inexplicable, King’s doubtless the pharmaceutical industry would have quickly mobilized to ensure widespread Fund. Rates are standardised for age and gender differences between geographies.
worldwide adoption. But what if an equal y dramatic impact was found to be obtainable by a 64 Health Service Journal (2011), “Quarter of trusts fail on value for money”, 18 August. careful y-tailored lifestyle intervention? In the decade since a landmark randomized control trial of 65 Care Quality Commission (2011), Dignity and nutrition inspection programme: national overview. a support intervention for weight and diet showed precisely that, the NHS has done nothing to 66 Health Service Journal (2011), “Fitness to practice”, 20 October.
implement it at scale. See: Diabetes Prevention Program Research Group (2002), “Reduction in British Medical Journal (2011), “Head of Healthcare Commission excised figures on excess deaths the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin”, New England Journal of from Mid Staffordshire report”, Vol. 342, 6 May. 68 Cabinet Office (2010), Applying behavioural insight to health.


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